Intake Form

Step 1 of 2

Personal Information

Address Verification and Medical History Update Form

Has your address, phone number, email address changed since your last visit? (Select all that apply)*

New Address

New Phone Number

New email address

No Changes

New Address*

Street AddressAddress Line 2CityStateZIP Code

New Phone Number*

New Email*

Areas of concern for today's treatment*

Has there been any change in your health history since your last treatment? (e.g. new medications, surgeries, inuries, accidents, etc...)*

Yes

No

Please list*

Address*

Street AddressAddress Line 2CityStateZIP Code

Phone*

Phone Type*

Home

Cell

Office

Date of Birth*

MM

DD

YYYY

Email*

Occupation*

Emergency Contact Name*

Emergency Contact Phone*

Who Referred You?*

Google

Yelp

Facebook

Road Sign

Friend or Relative

Spa Finder, Spa Week or Spa Wish

Other

Friend or Relative Name*

How would you like to receive your complimentary appointment reminders? Select all that apply*

Phone Call

Text

Email

Would you like to be added to our email list for specials, coupons and newsletters?*

Yes

No

Are you a student with a Valid School ID?*

Yes

No

Are you a current/retired military member?*

Yes

No

Select one:*

Active Duty

Veteran

Are you 70 years of age or older?*

Yes

No

I understand that it is solely my responsibility to keep the therapist updated on any changes in my
physical health, any surgeries, injuries, allergies, accidents or new medications I am taking and I further
understand that the company and the therapist shall not be liable for any purpose and for any reason,
should I fail to disclose this information.
If I experience any pain or discomfort during this treatment, I will immediately communicate that to the
therapist so the treatment can be adjusted.

Today's Date*

MM

DD

YYYY

Signature*

What are you here for today? (Select all that apply)*

To select multiple services:
For windows: Hold down the control (ctrl) button
For Mac: Hold down the command button

Hair Removal Intake Form

Have you used any Alpha Hydroxy Acid (AHA) or glycolic products in the past 48-72 hours?*

Yes

No

Are you using Retin-a, Renova or Accutane (an oral form of Retin-a)?*

Yes

No

Have you used Retin-a, Renova or Accutane in the last 12 months?*

Yes

No

Are you using any other skin thinning products and/or drugs?*

Yes

No

Are you exposed to the sun on a daily basis or are you considering spending more time in the sun soon?*

Yes

No

Do you use a tanning bed?*

Yes

No

Please select any of the following that apply to you:*

Varicose Veins

Poor Circulation

Third Choice

Recent Scar Tissue Epilepsy

Hyper Sensitive Skin

Edema

Prescribed Medication

Undiagnosed lumps/bumps

Moles

Diabetes

Skin Diseases

Warts

Psoriasis

Sunburn

Phlebitis

Pregnancy

None of the above

Do you have any open skin lesions or active herpes outbreak (cold sore or genital)?*

Yes

No

Have you been waxed/sugared before?*

Yes

No

What areas?*

Have you had any of the following procedures? Select all that apply*

Chemical Peel

Laser Resurfacing

Removal of Skin Cancer

Microdermabrasion

None of the above

Any Other Major Exfoliation Procedure?*

Yes

No

How long ago and on what areas?*

Are you currently taking medications?*

Yes

No

Please list all (including over the counter drugs/herbal supplements):*

What skin products do you regularly use on your skin?*

Have you ever been treated for cancer? If yes, when and what types of therapies were used?*

Please list any other illness/condition you are currently being treated for by a medical professional*

Please list any and all allergies you have:*

(Female clients) When is your next menstrual cycle due to begin?

Date Format: MM slash DD slash YYYY

(Always allow five days for menstrual cycle. Because of water retention
and for your own personal comfort, you should avoid hair removal two days before your cycle is due and two days after it is completed.)

Cancellation Policy/Fees

• Your appointment time was specifically reserved for you, so the courtesy of 24 hour notice for cancellation or rescheduling is appreciated.

• For all new clients, appointments over 90 minutes, couples, and packages; if you fail to give less than 6 business hour notice
of cancellation, you will be billed the full price of the treatment scheduled. If it is a morning appointment, we must receive your
call by the afternoon before to avoid the fee.

• For all existing clients; if you fail to give less than 1 business hour notice of cancellation, you will be billed the full price of the
treatment scheduled. If it is a morning appointment, we must receive your call by the end of the prior business day to avoid the
fee.

• Phone call, e-mail, and text message reminders will be provided as a courtesy to you. If you opt out of phone call reminders; please be
aware that an automated system sends our e-mails and text messages and we cannot guarantee their reliability; it is your responsibility to
remember your scheduled appointments. You can update your reminder method with our front desk staff at any time if your preferences
change.

• Bounced checks will incur a $25.00 fee for which a bill will be sent.

Treatment Policies and Etiquette

These policies are in place for your personal protection as well as for the professional dignity of the therapist. You will receive personal
instructions on what clothing to remove and how to prepare for the treatment. Please follow those instructions as well as the guidelines that
follow:

• Always wait for the therapist to leave the room before getting undressed. Keep a lower undergarment on and cover yourself with the sheet
as instructed. You will not be exposed by the therapist during the treatment, and should not attempt to expose yourself. Please do not get off
the table at the end of the treatment until the therapist has left the room.

• At no time will any sexual comments, suggestions, activities, or requests be tolerated. If this term is violated, the therapist has the right to
end the session, full payment is required, and no further treatments will be scheduled. This is a zero tolerance policy.

Please note that waxing/sugaring does have certain side effects such as skin removal, redness, swelling, tenderness, etc. Please initial each of the following in agreement with the statements.

• I have read the above information and if I have any concerns, I will address these with my skin therapist.*

• I give permission to my therapist to perform the waxing procedure we have discussed and will hold her and her staff harmless from any liability that may result from this treatment. *

• I have given an accurate account of the questions asked above including all known allergies or prescription drugs or products I am currently ingesting or using topically. *

• I understand my esthetician will take every precaution to minimize or eliminate negative reactions as much as possible. *

• I have read and understand the post-treatment home care instructions. *

• I am willing to follow recommendations made by my esthetician for a home care regimen that can minimize or eliminate possible negative reactions. *

• In the event that I may have additional questions or concerns regarding my treatment or suggested home product / post-treatment care, I will consult the esthetician immediately. *

• I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I certify that I have read, and fully understand the above paragraphs and that I have had sufficient opportunity for discussion to have any questions answered. *

• I understand the procedure and accept the risks. *

• I do not hold the esthetician, whose signature appears below, responsible for any of my conditions that were present, but not disclosed at the time of this skin care procedure, which may be affected by the treatment performed today.*

We have the right to refuse services for all waxing if proper hygiene is not followed. For Brazilian and bikini waxes, please use the provided
wipe to cleanse area.

Type Client Name*

Client Signature*

Today's Date*

MM

DD

YYYY

Lashes Intake Form

Do you have any signs of illness? (Examples: Red eyes, stuffy nose, seasonal allergies, etc.)*

Yes

No

Please Describe*

New medications, vitamins or herbal supplements since last visit?*

Yes

No

Please List*

Were any allergies discovered since your last visit? (Includes adverse reactions experienced)*

Have you had any procedures completed on your face or around your eyes within the last 48 hours? (Includes permanent cosmetics, skin-resurfacing, tinting, perming, surgeries, etc.)*

Yes

No

Please Describe*

When was the last time you wore cosmetic products on your face or around your eyes? (Include all worn within the last 3 days)*

Type of look desired by client:

Increase in length*

Subtle

Noticeable

Dramatic

Increase in volume*

Subtle

Noticeable

Dramatic

Other design requests:

Signature*

Today's Date*

MM

DD

YYYY

Massage Intake Form

Have you ever had a massage before?*

Yes

No

What brought you in today?*

Therapy

Pain Relief

Injury

Relaxation

Other

Please provide details:

Please describe your main concern for today's treatment.*

Please list any surgeries or medical procedures you have had along with the year it took place.*

Are you taking any of the following:*

Asprin

Anti-inflamatory

Pain relieving narcotics

Cholesterol Medication

Blood Pressure Medication

Thyroid Medication

Cancer Treatment Drugs

None of the Above

Check any of the following Respiratory or Circulatory issues you have or experienced in the past:*

Asthma

COPD

Hyper tension

Low Blood Pressure

Diabetes

Deep Vein Thrombosis (DVT)

Heart Condition

Pacemaker

None of the Above

Check any of the following Nervous, Skin or other issues you have or have experienced in the past:

Neuropathy

Spinal Cord Injury

Seizure disorders

Fungal Infection

Dermatitis/Eczema

Psoriasis

Rashes

Anxiety

Chronic Fatigue

HIV/AIDS

Lupus

Kidney Disease

Lyme Disease

Cancer

None of the Above

Are you pregnant?*

Yes

No

What is your due date?*

MM

DD

YYYY

Cancellation Policy/Fees

Your appointment time was specifically reserved for you, so the courtesy of 24 hour notice for
cancellation or rescheduling is appreciated.

For all new clients, appointments over 90 minutes, couples, and packages; if you fail to give less than
6 business hour notice of cancellation, you will be billed the full price of the treatment scheduled. If it is
a morning appointment, we must receive your call by the afternoon before to avoid the fee.

For all existing clients; if you fail to give less than 1 business hour notice of cancellation, you will be
billed the full price of the treatment scheduled. If it is a morning appointment, we must receive your
call by the end of the prior business day to avoid the fee.

Phone call, e-mail, and text message reminders will be provided as a courtesy to you. If you opt out of
phone call reminders; please be aware that an automated system sends our e-mails and text messages
and we cannot guarantee their reliability; it is your responsibility to remember your scheduled
appointments. You can update your reminder method with our front desk staff at any time if your
preferences change.

Bounced checks will incur a $25.00 fee for which a bill will be sent.

Treatment Policies and Etiquette

These policies are in place for your personal protection as well as for the professional dignity of the
therapist. You will receive personal instructions on what clothing to remove and how to prepare for the
treatment. Please follow those instructions as well as the guidelines that follow:

1. Always wait for the therapist to leave the room before getting undressed. Keep a lower
undergarment on and cover yourself with the sheet as instructed. You will not be exposed by the
therapist during the treatment, and should not attempt to expose yourself. Please do not get off the
table at the end of the treatment until the therapist has left the room.

2. At no time will any sexual comments, suggestions, activities, or requests be tolerated. If this term is
violated, the therapist has the right to end the session, full payment is required, and no further
treatments will be scheduled. This is a zero tolerance policy.